BARBARA AVED ASSOCIATES

Transcription

1 BARBARA AVED ASSOCIATES April 2018

2 Table of Contents INTRODUCTION... 2 METHODS... 3 FINDINGS... 4 I. Extent of Emergency Department Use for Preventable Dental Conditions... 4 II. Utilization of Dental Services... 6 Population-Based Utilization... 6 Medi-Cal Dental Utilization III. Other Important Dental-Related Issues Increasing Access to Dental Services for Children and Adults on the Central Coast / UPDATE OF SELECTED DATA 1

3 INTRODUCTION This report was prepared by Barbara Aved Associates (BAA), a Sacramento-based health consulting firm, for Dientes Community Dental Care, to benefit the continuing efforts of healthcare providers, community leaders, policy makers and advocates to improve oral health in Santa Cruz County. The report updates selected data presented in the comprehensive report Central Coast Oral Health Needs Assessment BAA produced for Dientes in April 2016 that formed the basis for the subsequent broad community response reflected in the group s Oral Health Access Strategic Plan While access to oral health services in Santa Cruz County has improved as a result of this community leadership and commitment, opportunities continue to exist for strengthening it. There is an increasing recognition of the importance of oral health to overall general health and a growing appreciation for the psychosocial impact of oral health influencing how people appear, work, enjoy life, speak, chew and socialize. Evidence continues to build for the association between periodontal disease and adverse health outcomes and the cost savings that are possible for those who receive preventive services and even those who can receive early treatment. Increasing Access to Dental Services for Children and Adults on the Central Coast / UPDATE OF SELECTED DATA 2

4 METHODS The Office of Statewide Health Planning and Development provided the data on emergency department visits for dental conditions using discharge data when an oral condition was the primary diagnosis. 1 The oral conditions were identified using the ICD-10 diagnosis codes; the codes were updated in October 2016 from the ICD-9 codes that were used in the earlier needs assessment. Some of the dental conditions are considered to be preventable (referred to as ambulatory care sensitive conditions in our original report), and are therefore regarded as potentially avoidable as they reflect conditions that would likely or possibly benefit from better prevention or primary care. 2 The Association of State and Territorial Dental Directors provided the ICD-10 dental codes OSHPD used to pull the data for this report, including the set considered preventable. 3 We retrieved population-based utilization data from the California Health Interview Survey (CHIS) the largest state health survey in the U.S. to examine dental service utilization among the overall Santa Cruz population. The most recently available comparative data were retrieved from Applied Survey Research Santa Cruz County Community Assessment Project (2015) and the American Dental Association Health Policy Institute. Data on Denti-Cal utilization came from the Department of Health Care Services (DHCS) Medi-Cal Dental program. DHCS staff does not prioritize what it considers ad hoc requests for dental data as made by this study to update the earlier needs assessment and consequently receipt of data required a 10-month wait using the Public Records Act to request it and intervention by Assemblymember Mark Stone s office to receive it. 1 Oral conditions as a secondary diagnosis were not analyzed due to very small occurrences. 2 Shortridge EF, Moore, JR. Use of Emergency Departments for Conditions Related to Poor Oral Health Care. Rural Health Research & Policy Centers, and NORC Walsh Center for Rural Health Analysis. Final Report, August Recommended Guidelines for Surveillance of Non-Traumatic Dental Care in Emergency Departments. Association of State and Territorial Dental Directors. July Personal communication August Non-traumatic dental conditions are defined as range of oral health needs that arise from common dental conditions, such as tooth decay and periodontal disease, and ordinarily do not require care in an emergency department. Increasing Access to Dental Services for Children and Adults on the Central Coast / UPDATE OF SELECTED DATA 3

5 FINDINGS Dental care, and in particular care for non-traumatic dental conditions, provided in emergency departments has been identified as both an indication of lack of access to the traditional primary care dental system, and an expensive and mostly ineffective alternative source of care. EDs generally provide only palliative care for oral problems (e.g., antibiotics and pain medication), addressing the symptoms, but not the cause of the problems. 4 Emergency Department Dental Visits by Santa Cruz County Residents In FY , there were 74,320 ED visits made by Santa Cruz County residents for all reasons. Of the ED visits, 821 (1.1%) were due to a primary oral condition diagnosis; the majority (60.9%) of these were made for a dental condition considered preventable (Table 1). 5 The highest proportion of preventable ED visits occurred among the age group 21-64, underscoring the especially high need for linkage to a dental home for non-senior adults. Table 1. ED Visits Made by Residents of Santa Cruz County 1 by Group, FY All s All Reasons 8,083 12,321 42,848 11,128 74,320 All Oral Conditions % % % 68.61% % Preventable Oral 2 Conditions % 57.46% % 32.29% % Preventable Oral as a % of all Oral 23.6% 50.4% 72.3% 47.1% 60.9% 1 County residents treated in Santa Cruz County. 2 Primary ICD-10 Codes. Source: Office of Statewide Health Planning and Development, Healthcare Information Resource Center. 4 Recommended Guidelines for Surveillance of Non-Traumatic Dental Care in Emergency Departments. Association of State and Territorial Dental Directors. July Data for ED visits considered avoidable should not be compared to previous years when ICD-9 Codes were used. Increasing Access to Dental Services for Children and Adults on the Central Coast / UPDATE OF SELECTED DATA 4

6 Overall, Santa Cruz County residents use of the ED for preventable dental conditions generally mirrored use statewide in FY Children age 0-5 in Santa Cruz County visited the ED at a slightly higher rate, 23.6%, than the statewide average, 21.4% (Figure 1). Figure 1. Percent of ED Visits for a Preventable Dental Condition 1 as a Percent of all ED Oral Visits Made by Residents of Santa Cruz County 2 and Statewide, FY % 50.5% 72.3% 74.3% 47.1% 49.4% 60.9% 63.2% 23.6% 21.4% All Santa Cruz County Statewide 1 Primary ICD-10 Codes. 2 County residents treated in Santa Cruz County. Source: Office of Statewide Health Planning and Development, Healthcare Information Resource Center. Emergency Department Dental Visits at County EDs In FY , there were 500 ED visits coded as a preventable dental condition at the 2 hospital ED facilities in Santa Cruz County (Table 2). Table 2. Number of ED Visits Made by Children and Adults to a Santa Cruz County ED 1 for a Preventable Dental Condition 2, FY Facility Children 0-20 Adults 21+ Total Dominican Hospital Watsonville Community Hospital Total By county of facility. 2 Primary ICD-10 Codes. Source: Office of Statewide Health Planning and Development, Healthcare Information Resource Center. Increasing Access to Dental Services for Children and Adults on the Central Coast / UPDATE OF SELECTED DATA 5

7 Emergency Department Dental Visits by Payer Source Public programs nearly entirely represented by Medi-Cal for the non-senior populations picked up the tab for the clear majority of Santa Cruz County residents ED preventable dental visits in FY (Figure 2). Just over 10% of the adult visits fell into the self-pay category generally people without dental insurance but not qualified to receive Medi-Cal dental benefits a category for which facilities are sometimes never paid. The biggest impact where prevention would have paid off relative to Medi-Cal was among children age 0-5. Figure 2. Payer Source for ED Visits Made by Santa Cruz Residents 1 for a Preventable Dental Condition, 2 by Group, FY % 73.6% 79.3% 82.8% 0.0% 20.8% 4.2% 5.7% 10.3% 10.3% 3.4% 6.9% 0-5 (n=24) 6-20 (n=53) (n=377) 65+ (n=29) Santa Cruz County Private Insur Pub Prog Self Pay 1 County residents treated anywhere. 2 Primary ICD-10 Codes. Source: Office of Statewide Health Planning and Development, Healthcare Information Resource Center. Population-Based Utilization Children Overall, the proportion of all children in Santa Cruz County visiting the dentist appears to be improving. According to the CHIS, 81.6% of Santa Cruz respondents reported taking their child age to a dentist within the past 6 months (Figure 3 on the next page). The proportion of children who had never visited the dentist dropped from 34% in 2013 to 15.3%--a 55% improvement. 6 For this measure, the CHIS question asks parents to include any child up to age 11 with teeth so it is possible the age group contains some children <1. Increasing Access to Dental Services for Children and Adults on the Central Coast / UPDATE OF SELECTED DATA 6

8 Figure 3. Time Since Last Dental Visit, Santa Cruz County, Children 81.6% 56.3% 50.3% 34.0% 30.8% 15.3% 18.9% 4.1% 3.1% 5.6% 0.0% 0.0% Never 6 mos or less 6 mos - 1 yr 1-2 yrs Source: California Health Interview Survey, multiple years. Note: some data statistically unstable due to small sample size Adults In 2016, over three-quarters (77.3%) of Santa Cruz County adults reported making a dental visit within the past year, up from two-thirds (64.9%) in 2014 a 19% improvement. The percentage who reported never making a visit, or not having one in more than 5 years, also dropped between 2014 and 2016; greater awareness of oral health benefits and expanded access could be important reasons for the improvement. Figure 4. Time Since Last Dental Visit, Santa Cruz County Adults 77.3% 64.9% 4.3% 1.0% 9.4% 7.0% 8.3% 9.3% 13.0% 5.4% Never 6 mos-1 yr 1-2 yrs 2-5 yrs 5+ yrs Source: 2014 and 2016 California Health Interview Survey Note: some data statistically unstable due to small sample size Increasing Access to Dental Services for Children and Adults on the Central Coast / UPDATE OF SELECTED DATA 7

9 Improvement in the use of dental care occurred at a slightly higher rate for low-income Santa Cruz County adults (Figure 5) a 21.5% change in annual dental visits between 2014 and 2016 than for adults in the county in general. Figure 5. Time Since Last Dental Visit, Santa Cruz County, Adults Living Under 200% Federal Poverty Level 47.9% 58.2% 7.3% 2.1% 9.7% 17.1% 18.0% 15.7% 15.7% 8.3% Never 6 mos-1 yr 1-2 yrs 2-5 yrs 5+ yrs Source: 2014 and 2016 California Health Interview Survey Note: some data statistically unstable due to small sample size While annual dental visits for all Santa Cruz County adults was more favorable in 2016 than 2014, those living under 200% of the federal poverty level reported 24.7% fewer visits, 58.2% vs. 77.3% (Figure 6). Figure 6. Time Since Last Dental Visit, Santa Cruz County, Total Adults and Adults Living Under 200% Federal Poverty Level 77.3% 58.2% 1.0% 2.1% 7.0% 8.3% 9.3% 15.7% 15.7% 5.4% Never 6 mos-1 yr 1-2 yrs 2-5 yrs 5+ yrs Total <200% FPL Source: 2016 California Health Interview Survey Note: some data statistically unstable due to small sample size Increasing Access to Dental Services for Children and Adults on the Central Coast / UPDATE OF SELECTED DATA 8

10 Although all of the adult groups represented in Figure 7 are not strictly comparable, other than the Santa Cruz County Community Assessment Project survey findings, population-based telephone surveys show that, overall, adults in Santa Cruz County visit the dentist at moderately higher rates than adults state- and nationwide. Figure 7. Percentage of Adults with Dental Care in the Last Year, Santa Cruz County, CA and U.S. * 77.3% 66.5% 70.3% 67.7% Santa Cruz County (ASR CAP) Santa Cruz County (CHIS) CA (CHIS) U.S. (ADA HPI) * Respondents answering yes when asked, In the past 12 months, have you had dental care? Sources: Applied Survey Research Santa Cruz County Community Assessment Project (2015); Santa Cruz County and California CHIS (2016), ADA Health Policy Institute analysis of Harris Poll survey data (2015). As Figure 8 makes clear, in 2016 poorer adults in Santa Cruz County visited the dentist for a specific dental problem more often than the general population of adults, 33.7% vs. 20.4%--a 65% difference. Figure 8. Reason for Adults Last Dental Visit, Santa Cruz County and California 71.8% 69.1% 62.5% 33.7% 25.7% 20.4% 7.8% 3.8% 5.1% Routine Check-up or Cleaning Specific Problem Both Santa Cruz County, All Santa Cruz County, <200% FPL CA Source: 2016 California Health Interview Survey Note: some data statistically unstable due to small sample size Increasing Access to Dental Services for Children and Adults on the Central Coast / UPDATE OF SELECTED DATA 9

11 Denti-Cal Utilization Annual Dental Visit In FY , an interim period between our baseline needs assessment report and the current update, DHCS began to use different parameters for reporting utilization than in prior years (and varying fiscal periods). Annual Dental Visit now represents the appropriate indicator for reporting Denti-Cal utilization. (The DHCS performance measure for ADV is the percentage of beneficiaries who had at least one dental visit during the measurement period.) This makes tracking from year to year more challenging as well as trying to make comparisons between fiscal and calendar years. In , Santa Cruz County children s utilization was 48.4%, more favorable than statewide at 43.7%. (Note that in 2014, using different eligibility criteria, county children age 0-20 utilization was 58.6% compared to state utilization at 52.5%). Adults in the county visited the dentist at essentially the same rate as adults in the rest of the state, 20.5% (Figure 9) essentially reflecting the drop that occurred in Medi-Cal dental benefits in Figure 9. Annual Dental Visit, Children and Adults, % 43.7% 20.5% 20.6% Children ( 0-20) Adults ( 21+) Santa Cruz County California Note: Beneficiaries who were eligible for at least 90 days continuously between Oct 2015 and Sep Source: Department of Health Care Services Medi-Cal Dental Services Division. The Denti-Cal utilization data in Table 3 were the most recent data at the time of our request, June 2017). The table displays the number of child and adult beneficiaries in Santa Cruz, the number who utilized at least one dental service and the utilization rate. The data are broken out by type of provider. Table 3. Number of Denti-Cal Beneficiaries, Users, and Utilization Rate, 2016 Total FQHC-Only Non-FQHC Only Group Beneficiaries 1 Users Utilization Users Utilization Users Utilization 0-3 9,383 3, % 1, % % 4-5 5,357 2, % % % ,740 5, % 2, % 1, % ,336 13, % 2, % 4, % ,195 8, % 2, % 3, % 65+ 6,196 1, % % % Total 2 93,467 29, % 7, % 10, % Source: Medi-Cal Dental Division, April 11, Includes unduplicated beneficiaries with no continuous eligibility requirements. 2 To avoid duplication, total does not include age group 0-3. Increasing Access to Dental Services for Children and Adults on the Central Coast / UPDATE OF SELECTED DATA 10

12 Children age 0-5 with Denti-Cal made a higher percentage of dental visits to an FQHC-only provider than to private dentists; after age 6, private dentists saw a greater proportion of each age group (Figure 10). Figure 10. Denti-Cal Utilization Rates by Type of Provider Utilized by Group, % 38.8% 33.0% 16.2% 15.9% 16.1% 15.3% 11.6% 9.5% 48.3% 18.1% 10.0% 31.4% 25.1% 19.6% 11.3% 11.6% 7.6% 8.4% 5.3% 5.0% Total Total FQHC Only Non-FQHC Only Source: Medi-Cal Dental Division, As Figure 11 indicates, in 2016 Santa Cruz County children and adults had more favorable Denti- Cal utilization rates than California rates at every age group except for individuals age 75 and older. Figure 11. Denti-Cal Utilization Rate, Santa Cruz County Compared to Statewide, % 50% 40% 30% 20% 10% 0% Santa Cruz County 36.8% 59.8% 63.9% 56.4% 44.7% 28.6% 17.9% 20.2% 23.2% 25.5% 19.5% California 23.2% 51.7% 58.8% 51.9% 41.7% 27.2% 18.2% 20.6% 23.0% 23.0% 20.6% 75+ Santa Cruz County California Source: DHCS Medi-Cal Dental Division. Increasing Access to Dental Services for Children and Adults on the Central Coast / UPDATE OF SELECTED DATA 11

13 Denti-Cal Utilization by Zip Code Table 4 shows a summary of the Denti-Cal utilization rates by selected zip code for children (age 0-20) and adults (age 21+) in Santa Cruz County, sorted by highest utilization rates. The ranking did not change between the 2014 and 2015 assessments. Table 4. Denti-Cal Beneficiaries and Utilization, Selected Santa Cruz Zip Codes, Zip Code Children Total Users % Utilization Zip Code Beneficiaries Beneficiaries Adults Total Users % Utilization & ,330 10, % ,117 1, % ,895 1, % & ,865 3, % 950 (all others) 7,589 2, % 950 (all others) 9,672 1, % ,544 1, % ,192 1, % & , % & , % % Source: DHCS Medi-Cal Dental Division, April 11, Zip codes are in rank order by age group for each county. Three-digit zip codes indicates where DHCS suppressed data. The all others next to the 3-digit zip code indicates that all other zip codes with those beginning with 3 digits are included in that data set. This differentiates it from the more specific zip codes. Note: the data for all tables were pulled by the beneficiary s county of residence. The data were not based on place of service or claims data. Children s utilization remained relatively consistent from 2014 to 2016 in all of the zip codes examined except the 951- and 988- areas, where there was about a 20% drop between the two periods (Figure 12). Figure 12. Utilization of Children age 0-20 by Selected Zip Codes, Santa Cruz County, 2014 and % 50.7% 42.4% 43.3% 39.0% 38.9% 37.5% 37.2% 34.0% 31.7% 23.4% 18.6% & (all others) & Source: DHCS Medi-Cal Dental Division. Increasing Access to Dental Services for Children and Adults on the Central Coast / UPDATE OF SELECTED DATA 12

14 Among the adult population, utilization rose in each zip code from 2014 to 2016 with the greatest increase in the zip code (Figure 13). Figure 13. Utilization of Adults 21+ by Selected Zip Codes, Santa Cruz County, 2014 and % 20.1% 17.4% 17.1% 17.1% 15.8% 16.1% 15.9% 14.7% 13.5% & (all others) & Source: DHCS Medi-Cal Dental Division. Figure 14 displays dental utilization in the various local, statewide and national programs for children and adults. Although the age ranges for some of these programs differs somewhat, the data provide a picture of the similarity to relatively more favorable comparison, on average, of Santa Cruz County dental utilization with state and U.S. experience. Although California s Medi-Cal managed care rate is only applicable to the dental managed care program, and not the traditional Denti-Cal fee-for-service system used statewide, we show it as another basis of comparison. Figure 14. Dental Utilization, Various Populations of Children and Adults Santa Cruz County Denti-Cal ( ) California avg ( ) U.S. Medicaid avg (2015) CA Dental managed care (2016) 20.5% 20.8% 18.4% 48.4% 45.9% 48.5% 43.7% 40.2% Children ( 0-20) Adults ( 21-64) Sources: DHCS Medi-Cal Dental Division; Delta Dental; U.S. Centers for Medicare and Medicaid Services. Increasing Access to Dental Services for Children and Adults on the Central Coast / UPDATE OF SELECTED DATA 13

15 Use of Sealants Dental sealants a thin, plastic coating painted on the chewing surfaces of the back teeth act as a barrier to help protect teeth from bacteria and acids. In 2015, Santa Cruz County children received significantly fewer sealants than children statewide, putting them at higher risk for tooth decay (Figure 15). 7 Figure 15. Children s Use of Dental Sealants, % 8.5% 8.9% 4.1% Santa Cruz County California Source: Department of Health Care Services Medi-Cal Dental Services Division. Fluoride Varnish Fluoride varnish is a dental treatment that can help prevent tooth decay or stop it from getting worse by strengthening tooth enamel (the outer coating on teeth). Pediatricians and other primary care providers such as family practice physicians and nurse practitioners are trained to apply fluoride varnish (and can be reimbursed by Medi-Cal for it) because many young children do not see or have access to a dentist until they are older. In Santa Cruz County, the number of children 0-5 with Medi-Cal who received a fluoride varnish treatment from a non-dentist rose from 206 in 2012 to 764 in 2016, possibly reflecting increased efforts to train primary care providers in oral health (Table ). 8 It is not clear why no children older than age 6 were reported. Table. Fluoride Varnish by Non-Dentists, Santa Cruz County Group Number of Users Source: DHCS Medi-Cal Dental Division. 7 Note: the Denti-Cal data website that shows utilization of sealants by county for 2016 for some reason does not show Santa Cruz County though it does includes most other counties; California s 2016 sealant rates are 17.2% for age 6-9 and 9.2% for age Data by type of primary care provider (for example, pediatricians vs. nurse practitioners) was not available from DHCS. Increasing Access to Dental Services for Children and Adults on the Central Coast / UPDATE OF SELECTED DATA 14

16 Use of a Baby Bottle during Sleep On average, fewer Santa Cruz County parents report putting their child to sleep with a bottle in the mouth, a practice which can cause serous tooth decay, than parents statewide (Figure 16). A higher percentage of low-income parents, however, report their children taking a nap or being put to be with a bottle. Figure 16. Percent of Parents Who Routinely Use a Bottle for Children Under 6 during Sleep or Nap 4.1% 4.5% 6.5% 5.5% All children Children 0-200% FPL Santa Cruz County California Source: 2016 California Health Interview Survey Condition of Adult Teeth Adults with Medi-Cal report higher rates of average, poor and bad self-perceived oral health status compared to adults with other forms of health insurance. 9 While 15.4% of Santa Cruz County adults overall reported the condition of their teeth in 2016 as excellent and 37.6% as very good, only 9.9% and 9.5%, respectively, of low-income adults were able to report such conditions (Figure 17). Figure 17. Adults Self-Reported Condition of Teeth, % 30% 20% 10% 0% Excell ent Very Good Source: 2016 California Health Interview Survey Good Fair Poor No Nat'l Teeth Santa Cruz County, All 15.4% 37.6% 28.5% 12.0% 5.4% 1.1% Santa Cruz County <200% FPL 9.9% 9.5% 37.5% 26.7% 11.6% 4.8% California 12.1% 25.5% 33.1% 18.3% 8.9% 2.1% Santa Cruz County, All Santa Cruz County <200% FPL California 9 Yarbrough C et al. Key Differences in Dental Care Seeking Behavior between Medicaid and Non-Medicaid Adults and Children. American Dental Association. Health Policy Institute Research Brief, September Increasing Access to Dental Services for Children and Adults on the Central Coast / UPDATE OF SELECTED DATA 15